Inspection Report Summary
Most inspections found no deficiencies, with the facility consistently maintaining cleanliness, proper documentation, and compliance with safety and health regulations. The most recent report from March 25, 2025, was perfect with no deficiencies cited. Earlier complaint investigations included serious incidents such as a resident eloping from a locked memory care unit and a staff member sending inappropriate photos of residents; these resulted in isolated deficiencies related to staffing levels and confidentiality. The facility addressed safety concerns by increasing staff monitoring and providing additional training, showing improvement over time. Several complaint investigations were unsubstantiated, and no fines, license suspensions, or enforcement actions were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 100
Capacity: 114
Deficiencies: 0
Mar 25, 2025
Visit Reason
The inspection was an unannounced 1-Year Required annual inspection conducted to evaluate compliance with licensing requirements for the assisted living and memory care facility.
Findings
The facility was found to be clean, orderly, and compliant with safety and health regulations. All staff and resident documentation were in order, emergency supplies and disaster preparedness were adequate, and no deficiencies were cited during the visit.
Report Facts
Residents bedridden capacity: 14
Hospice waiver capacity: 12
Sample size of sinks tested for hot water temperature: 9
Sample size of staff files reviewed: 10
Sample size of resident files reviewed: 10
Sample size of residents' medications spot-checked: 8
Date of last fire extinguisher service: Jan 10, 2025
Date of last disaster drill: Mar 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Executive Director | Met with Licensing Program Analyst during inspection and named as Administrator/Executive Director |
| Robert Frank | Licensing Program Analyst | Conducted the inspection visit |
| Debbie Spencer | Office Director | Greeted Licensing Program Analyst upon arrival |
Inspection Report
Annual Inspection
Census: 102
Capacity: 114
Deficiencies: 0
Apr 25, 2024
Visit Reason
Unannounced 1-Year Required Visit to evaluate compliance with regulations for an assisted living and memory care facility.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations including infection control, emergency preparedness, and resident care documentation. No deficiencies were cited during the visit.
Report Facts
Staff on-site: 32
Residents bedridden capacity: 14
Hospice waiver capacity: 12
Hot water temperature sample size: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator/Executive Director | Met during inspection and named in report. |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection. |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 114
Deficiencies: 0
Feb 2, 2024
Visit Reason
The visit was an unannounced case management inspection triggered by a report of sexual assault abuse involving a resident at the facility.
Findings
The investigation found that a resident reported a sexual assault by an unknown suspect. The administrator notified police and the resident was transported to the hospital. No deficiencies were cited during this inspection.
Complaint Details
The complaint involved a sexual assault reported by resident R1 on 1/31/2024. The suspected abuser is unknown. The facility reported the incident to police and the resident's responsible party. Hospital discharge information and police report were not available at the time of inspection.
Report Facts
Residents present: 101
Facility capacity: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst and involved in reporting and handling the abuse incident |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 114
Deficiencies: 0
Jan 17, 2024
Visit Reason
The visit was an unannounced case management inspection regarding an incident report received on 2024-01-08 involving alleged abuse of a resident by self-neglect, which resulted in hospitalization.
Findings
The investigation found that the resident had jumped from a second-floor window resulting in a fractured back and hospitalization. The facility took immediate corrective actions including fitting safety window restrictors and conducting additional staff training on suicide precautions. No deficiencies were cited during this inspection.
Complaint Details
The complaint involved abuse of resident (R1) by self-neglect leading to a 72-hour hold and hospitalization. The incident was cross-reported to police (report #24-271). The resident remains hospitalized with a fractured back and will not be returning to the facility. The complaint was investigated with no deficiencies cited.
Report Facts
Facility capacity: 114
Incident date: Jan 6, 2024
Incident report received date: Jan 8, 2024
Window restrictor opening limit: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst and involved in incident response |
| Christi Coppo | Licensing Program Analyst | Conducted the case management inspection |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 114
Deficiencies: 0
Jan 4, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report received on 12/15/2023 regarding alleged abuse of a resident in the form of theft of a cellphone.
Findings
The investigation found that the resident's cellphone was missing and presumed stolen after staff accidentally washed it and returned it to the resident. The facility conducted an investigation, cross-reported the incident to appropriate parties, and filed a police report. No deficiencies were cited during this investigation.
Complaint Details
The complaint involved alleged theft of a resident's cellphone. The incident was substantiated by the facility's investigation and police report filing. The resident's apartment was searched without locating the phone, and the cellphone carrier was unable to locate it remotely.
Report Facts
Approximate value of stolen cellphone: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Named in relation to the incident report and investigation |
| Christi Coppo | Licensing Program Analyst | Conducted the case management visit and investigation |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 114
Deficiencies: 1
Oct 20, 2023
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report received on 2023-10-06 regarding a resident who was found missing from the facility.
Findings
The investigation found that resident R1, diagnosed with dementia and residing in Memory Care, eloped from a locked memory care unit and was later found at a hospital emergency room with no injuries or new diagnoses. The facility increased staff monitoring and conducted additional staff training following the incident. A deficiency was cited for failing to meet the requirement of adequate direct care staff to support residents' needs.
Complaint Details
The visit was complaint-related, triggered by an incident report about resident R1 eloping from the facility. The resident was found safe at a hospital ER. The complaint was substantiated by the cited deficiency.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs, evidenced by resident R1 eloping a locked memory care unit. | Type B |
Report Facts
Census: 103
Total Capacity: 114
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Named in relation to the incident and facility response |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 114
Deficiencies: 0
Oct 3, 2023
Visit Reason
The inspection was an unannounced Case Management-Incident visit to discuss three incidents reported by the facility, including a missing resident's jewelry, a resident's fall resulting in a hip fracture, and a rodent sighting in an apartment.
Findings
No deficiencies were observed or cited during the inspection. The facility took appropriate actions including contacting responsible parties, reassessing the resident after the fall, and eradicating the rodent issue with pest control measures.
Complaint Details
The visit was complaint-related to three incidents: missing jewelry reported on September 20, 2023; a resident's left hip fracture from a fall on September 25, 2023; and a rodent sighting on September 27, 2023. The facility responded appropriately to each incident. No deficiencies were cited.
Report Facts
Incident dates: September 20, 2023; September 25, 2023; September 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with during inspection and involved in incident reporting and response |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header |
Inspection Report
Capacity: 114
Deficiencies: 1
Aug 30, 2023
Visit Reason
The inspection was an unannounced Case Management - Incident visit conducted to investigate an incident involving inappropriate photos of two residents sent via cellular device and email to the Administrator.
Findings
The Licensing Program Analyst found that a staff member sent inappropriate photos of two residents to the Administrator, which posed an immediate health, safety, and personal rights risk. The staff member was written up and the Administrator was educated on the prohibition of resident photography on personal cell phones.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure confidential treatment of residents' records and personal information, as emails depicting inappropriate photos of two residents were sent to the Administrator via cellular device and email. | Type B |
Report Facts
Capacity: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met during inspection and involved in incident |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Supervisor of the Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 114
Deficiencies: 0
Jun 22, 2023
Visit Reason
The inspection was conducted as a Case Management-Incident Inspection following an incident report of a resident fall, injury, and subsequent hospital visit.
Findings
No deficiencies were observed or cited during the inspection. The resident was reported to be doing well and prescribed medication for pain. The Care Plan will be updated with the family.
Complaint Details
The visit was complaint-related due to an incident report forwarded on June 10, 2023, concerning a resident fall and injury. The complaint was investigated and no deficiencies were found.
Report Facts
Capacity: 114
Census: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Facility Administrator present during the inspection |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident Inspection |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 114
Deficiencies: 0
May 8, 2023
Visit Reason
The inspection was conducted as a Case Management-Incident Inspection following incidents submitted to the Community Care Licensing on April 22, 2023, and May 5, 2023, including a resident-to-resident altercation.
Findings
The facility was found to have followed all proper procedures related to the incidents reviewed, including confirming that a resident was not on a Special Diet and that care plans will be updated for involved residents. No deficiencies were observed or cited during the inspection.
Complaint Details
The visit was complaint-related, triggered by incident reports submitted on April 22, 2023, and May 5, 2023. The complaint was investigated and found to be unsubstantiated as no deficiencies were cited and residents had no recollection of the altercation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection and interviewed regarding incident reports. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident Inspection and reviewed incident reports. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 114
Deficiencies: 0
Feb 23, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation that staff interfered with resident visiting at the facility.
Findings
The investigation found the allegation to be unfounded after reviewing records, conducting interviews, and observing the resident. No one was denied entry to visit the resident, and no deficiencies were observed during the inspection.
Complaint Details
The allegation that staff interfered with resident visiting was investigated and found to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.
Report Facts
Facility capacity: 114
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Gravelyn | Administrator | Met with during inspection and exit interview |
| Farhaan Sarangi | Licensing Program Analyst | Conducted amended report and investigation |
| Erik Gonzalez Campos | Evaluator | Conducted initial complaint investigation visit |
Inspection Report
Annual Inspection
Census: 90
Capacity: 114
Deficiencies: 0
Feb 23, 2023
Visit Reason
The inspection was an unannounced required 1-year inspection focused on infection control practices and procedures at the facility.
Findings
The facility was found to be clean and in good repair with sufficient food supplies, operational safety equipment, and proper infection control measures including staff training and COVID-19 precautions. No deficiencies were observed during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Gravelyn | Administrator | Met with Licensing Program Analyst during inspection and discussed resident/staff record keeping. |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the unannounced required 1-year inspection. |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 114
Deficiencies: 0
Dec 28, 2022
Visit Reason
The inspection was a case management visit conducted due to a self-reported SOC341 incident received by Community Care Licensing on 2022-12-20. The facility conducted an internal investigation and reported the incident to the Santa Rosa Police Department.
Findings
No deficiencies were cited during the inspection. The Licensing Program Analyst will follow up by requesting the police report related to the incident.
Complaint Details
The visit was complaint-related based on a self-reported incident (SOC341) received on 2022-12-20. The facility conducted an internal investigation and reported the incident to the police. Follow-up includes requesting the police report.
Report Facts
Capacity: 114
Census: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Gravelyn | Administrator | Met with Licensing Program Analyst during inspection |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the case management inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 114
Deficiencies: 0
Dec 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 08/16/2022 regarding neglect, failure to address change in resident's condition, and failure to report incidents including death, fall, and pressure injury.
Findings
The investigation found no preponderance of evidence to substantiate the allegations of neglect, failure to address change in condition, or failure to report incidents. The allegations were determined to be unsubstantiated and no deficiencies were cited during the inspection.
Complaint Details
The complaint involved allegations of neglect/lack of care causing an unstageable pressure injury, failure to address a resident's change in health condition, and failure to report death, fall, and pressure injury. The investigation concluded all allegations were unsubstantiated.
Report Facts
Complaint Control Number: 21-AS-20220816152630
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Teresa Weerts | Health Services Director | Met with Licensing Program Analyst during inspection and exit interview |
| Kimberley Mota | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 114
Deficiencies: 1
Nov 22, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including resident falls, skin tears, delayed medical attention, physical abuse, hygiene neglect, improper medical documentation, malnutrition, and failure to inform representative of condition changes.
Findings
The investigation found one allegation substantiated regarding failure to arrange timely podiatric care resulting in excessive toenail length and dry cracked skin, posing immediate risk to resident health. Other allegations including unwitnessed fall, skin tears, delayed medical attention, physical abuse, hygiene neglect, improper documentation, malnutrition, and failure to inform representative were found unsubstantiated or unfounded based on evidence reviewed.
Complaint Details
Complaint investigation was conducted based on allegations received on 05/31/2022. The complaint included multiple allegations such as unwitnessed fall, skin tears, delayed medical attention, physical abuse, hygiene neglect, improper medical documentation, malnutrition, and failure to inform resident's representative. The investigation concluded the complaint was partially substantiated (podiatric care issue) and partially unsubstantiated or unfounded for other allegations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to arrange timely podiatric care for resident resulting in excessively long nails and toes in need of care, posing immediate risk to health and personal rights. | Type A |
Report Facts
Capacity: 114
Census: 79
Deficiencies cited: 1
Plan of Correction Due Date: Nov 25, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Oversaw complaint investigation |
| Kevin Booth | Administrator | Facility administrator named in report |
| Lydia Gravelyn | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 114
Deficiencies: 1
Jun 24, 2022
Visit Reason
The inspection was conducted as a Case Management Inspection regarding an incident report received by Community Care Licensing on 2022-06-09 involving a resident eloping from memory care.
Findings
The Licensing Program Analyst observed that exits to outdoor patio areas and the front entrance were armed with alarms, but a resident was able to exit one alarmed door and one delayed egress door, posing an immediate health and safety risk. Deficiencies were cited related to care of persons with dementia and safety measures for wandering behaviors.
Complaint Details
Inspection was triggered by an incident report of a resident eloping from memory care on June 8, 2022. The complaint was substantiated as deficiencies were found.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet requirements for safety measures addressing behaviors such as wandering, aggressive behavior, and ingestion of toxic materials, evidenced by a resident exiting an alarmed door and a delayed egress door. | Type A |
Report Facts
Residents in care during inspection: 31
Census: 73
Total Capacity: 114
Deficiency count: 1
Plan of Correction Due Date: Due date stated as 07/01/2022 (converted date not numeric)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Tammy Kirby | Regional Memory Care Specialist | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Kimberley Mota | Licensing Program Manager | Supervisor and Licensing Program Manager named in report |
Inspection Report
Original Licensing
Census: 73
Capacity: 114
Deficiencies: 1
Jun 24, 2022
Visit Reason
The visit was an unannounced Post Licensing Inspection conducted to evaluate the facility's compliance following licensing.
Findings
The facility was found to be clean and in good repair. Infection control measures including COVID screening and staff vaccination were in place. Medications and toxins were securely stored. However, a written plan was requested to provide fire extinguisher access to memory care staff by July 1, 2022.
Deficiencies (1)
| Description |
|---|
| Fire extinguishers were behind locked cases with access only by maintenance coordinator; facility requested to submit a written plan to provide access to memory care staff. |
Report Facts
Capacity: 114
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the Post Licensing Inspection and noted findings |
| Tammy Kirby | Regional Memory Care Specialist | Met with Licensing Program Analyst during inspection and participated in exit interview |
Inspection Report
Census: 73
Capacity: 114
Deficiencies: 0
Jun 2, 2022
Visit Reason
The visit was conducted as a Case Management - Other type of visit, specifically to return the file for a resident (R1).
Findings
The Executive Director reviewed the contents of the resident file and confirmed it was returned complete and undamaged per regulation. An exit interview was conducted with the administrator and a copy of the report was emailed to the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Safoora Ahmed | Executive Director | Met with Licensing Program Analyst during the visit and reviewed resident file. |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the unannounced visit and file return. |
Inspection Report
Original Licensing
Census: 64
Capacity: 114
Deficiencies: 0
Apr 15, 2022
Visit Reason
The inspection was an unannounced pre-licensing visit conducted to evaluate the facility for initial licensing approval.
Findings
The facility was found to have appropriate furnishings, safety features such as grab bars, smoke alarms, sprinkler systems, and locked medication storage. Staff CPR and First Aid certifications were current, and sufficient food supplies were observed. No deficiencies or violations were noted in the report.
Report Facts
Resident files reviewed: 5
Current CPR certificates: 10
Water temperature: 112.2
Fire extinguisher inspection date: Jan 22, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Weerts | Health Services Director | Met with Licensing Program Analyst during inspection |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the pre-licensing inspection |
Inspection Report
Capacity: 114
Deficiencies: 0
Feb 24, 2022
Visit Reason
The visit was an office type evaluation related to a Change of Ownership (CHOW) application, including a Component II telephone call to verify the applicant and administrator's understanding of Title 22 regulations and facility operation.
Findings
The applicant and administrator successfully completed Component II via telephone, confirming understanding of facility operation, staff qualifications, program policies, and application document review including criminal record clearance, health screening, and other licensing requirements.
Loading inspection reports...
